34 St. Peter Street, Test Cert Cointractoir's MateirilaIll and I,,, t Certificate -foie Albovegiround Ill"1iiil iiiinm
Procedure: Upon completion of work, inspection and tests shall be made by the contractor's representative and witnessed by
an owner's representative. All defects shall be corrected and system left in service before contractor's personnel finally leave
the job.
A certificate shall be filled out and signed by both representatives. Copies shall be prepared for approving authorities,owners,
and contractor. It is understood the owner's representative's signature in no way prejudices any claim against contractor for
faulty material,poor workmanship,or failure to comply with approving authority's requirements or local ordinances.
Property Name: St Theresa of Salem,LLC
Property Address: 34 St Peter St Salem,MA 01970 Date: 6-20-2021
Accepted by Approving Authorities(Names).
Salem Fire Prevention
Address: 29 Fort Ave Salem,MA 01970
Plans Installation conforms to accepted plans: 0 Yes ❑No
Equipment use is approved: ❑Yes ❑No
If no,explain deviations:
Has person in charge of fire equipment been instructed as to 0 Yes ❑ No
location of control valves and care and maintenance?:
If no,explain:
Instructions Have copies of the following been left on the premises?:
1.System components instructions 0 Yes ❑No
2.Care and maintenance instructions 0 Yes ❑No
3.NFPA 25 0 Yes ❑No
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Location of ppI.. BIIIng S stem Y right ht side
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Make Model Year Office Size Quantity Temperature
Manufacture Ratin
TY3131 .............................................TyCo............................................................................2021................................. 112 1..6..........................................200...d.e.g ree................
Sprinklers .TY.3.231.......................................... T co 2021 112 22 .2.....0.....0........d.....e.... ree
. ........ ..............
..
TY3231 Tyco............................................. 2021 112 148 155 Degree
Pipe and Type of Pipe: Steel and CPVC Pipe
...... ................... ....................................................................................................................................................................................................................................................................................................................................................................................
FittingsType of Fittings: Cast iro.n...fittings a.nd...C.PVC fittings.............................................................................................................................................................................................................................................................................................
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Alarm Valve Alarm Device Maximum Time to Operate
Through Test Connection
or Flow Type Make................................................ Model Min Sec
Indicator Vane WFD System Sensor 37
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aY...........a........e................. Q...O............:.............................
Make Model Serial# Make Model Serial#
Dry Pipe Time to Trip Through Water Air Trip Point Time Water Reach Alarm Operated
Operating Test..Connection Pressure Pressure Pressure ...Air..Press.. Test Outlet Properly?
Test Min Sec PSI PSI PSI Min Sec Yes No
Without
Q.O.D.
.................With................
Q.O.D.
Operation: ❑Pneumatic ❑ Electric ❑ Hydraulic
Piping Supervised? ❑Yes ❑ No Detecting Media Supervised? ❑Yes ❑No
...............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
Deluge and Does valve operate from the manual trip, remote,or both control stations? ElYes ElNo
Preaction Is there an accessible facility in each circuit for testing? ❑Yes ❑ No
Valves If no,explain:
........
Each Circuit Operate Each Circuit Operate Maximum Time to
Make Model Supv. Loss Alarm? Valve Release? Operate Release
Yes No Yes in No M Sec
........� ....... L..... I .......
.......................................................................... ........................................................................................................................
Residual Pressure Flow
Pressure Location& Make& Static Pressure Flow�inRate
Setting (.................
Reducing Floor Model Left si Outlet si Inlet(psi) Flow m
Valve ............................................ .......... .(P ) (g.P........)
Hydrostatic: Hydrostatic tests shall be made at not less than 200 psi(13.6 bars)for 2 hours or 50 psi
(3.4 bars)above static pressure in excess of 150 psi(10.2 bars)for 2 hours. Differential dry-pipe valve
Test clappers shall be left open during the test to prevent damage. All aboveground leakage shall be stopped.
Description Pneumatic: Establish 40 psi(2.7 bars)air pressure and measure drop,which shall not exceed 1 '/2 psi
(0.1 bars)in 24 hours. Test pressure tanks at normal water level and air pressure and measure air
pressure drop,which shall not exceed 1 '/2 psi(0.1 bars)in 24 hours.
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All piping hydrostatically tested at 200 psi bars for 2 hrs If no,state reason:
Dry piping pneumatically tested ❑Yes ❑No
Equipment operates properly ❑Yes ❑No
Do you certify the sprinkler contractor that additives and corrosive chemicals sodium silicate or
Y Y as p
derivatives of sodium silicate,brine,or other corrosive chemicals were not used for testing systems or
stopping leaks? ❑� Yes ❑No
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Drain Test Reading of gauge located near water Residual pressure with valve test in
Tests supply test connection: 75 psi (_bars) I connection open wide:60 psi (_bars)
Underground mains and lead in connections to system risers flushed before connection made to sprinkler
piping:
Verified by copy of the U-Form No.85B ❑Yes ❑No Other(explain):
Flushed by installer of underground sprinkler piping ❑Yes ❑No
If powder-driven fasteners are used in concrete,has representative If no,explain:
sample testing been satisfactorily completed? ❑Yes ❑No
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Blank Number Used Locations Number Removed
Testing
Gaskets
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Welded Piping? Yes Is No
If yes:
Do you certify as the sprinkler contractor that welding procedures comply with the requirements of at least
Y Y p 9p PY q
AWS D10.9,Level AR-3? ❑Yes ❑No
D
Weldingo you certify that the welding was performed b welders qualified in compliance with the requirements of
at least AWS D10.9, Level AR-3? ❑Yes H No
Do you certify that welding was carried out in compliance with a documented quality control procedure to
ensure that all discs are retrieved,that openings in piping are smooth,that slagand other welding residue
is removed,and that the internal diameters of pipingare not penetrated? Yes ❑ No
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Cutouts Do..............you certify that.....you have a control feature to en.....................................................................................................................................................sure that all cutouts(discs)are retrieved?
■ Y N
Discs
Yes o
...............................................................................Nameplate provided? V Yes ❑ No If no,explain: .....................
Hydraulic P P � P
Data
Nameplate
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Date left in service with all control valves open:
Remarks
12-9-2021
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Name of S P rinkler Contractor:
Test Charlie Rodgers Front-Line Fire Protection, LLC
Witnessed For Property Owner(signed) TITLE DATE
By Fnr Rnrinlrlor r nntrnotnr(cirined) TITLE DATE
G%� G.e.n.e.ra.I.....Manager 12-9-2021
Additional Explanation ana tes:
Revised: 2013-May-02 Building Inspections Forms and Handouts
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